DME Request Form

DME Request Form
Client Name*

First NameLast Name
Client Date of Birth*

MonthDayYear
Date
Client Delivery Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Clinician Name*

First NameLast Name
Clinician email*
example@example.com
Order Date*

MonthDayYear
Date
Ordering Provider*

First NameLast Name
Type of DME*

Bathing Seats (NOT covered for Medicare or MCR ADV pts)Blood Sugar Meter, Strips & LancetsCane/crutchesCommode ChairContinuous Glucose Monitors (Dexcom/FreeStyle Libre)CPAP MachineHospital Bed & accessoriesLymphedema PumpsNebulizer & Nebulizer MedicationOxygen Equipment & accessoriesPatient LiftPressure-reducing support surfacesPT/INR MachineSuction PumpTraction EquipmentWalker/RollatorWheelchairs & scootersWedges (Foam/Pillow)Wound Vac- Not Supplies, for the actual Wound Vac Unit
Date of most recent Face-to-face with Provider*

MonthDayYear
Date
Weight of Client: lbs*
Height of Client: feet & inches*
Diabetes ICD-10 Codes*

E11.9- Type 2 diabetes mellitus without complicationsE11.8- Type 2 diabetes mellitus with unspecified complicationEll.69- Type 2 diabetes mellitus with other specified complicationE11.65- Type 2 diabetes mellitus with hyperglycemiaE11.649- Type 2 diabetes mellitus with hypoglycemia without comaE11.641- Type 2 diabetes mellitus with hypoglycemia with comaE10.9- Type 1 diabetes mellitus without complicationsE10.8- Type 1 diabetes mellitus with unspecified complicationsE10.69- Type 1 diabetes mellitus with other specified complicationE10.65- Type 1 diabetes mellitus with hyperglycemiaE10.649- Type 1 diabetes mellitus with hypoglycemia without comaE10.641- Type 1 diabetes mellitus with hypoglycemia with coma
Do we have a recent A1C level?*

YesNo
What was the most recently A1C level?
What date was the most recent A1C drawn on? *

MonthDayYear
Date
Has the client been testing their blood glucose with a standard monitor?*

YesNo
How many times a day does/will the client test their blood glucose? *
Is the Client currently taking Insulin?*

YesNo
Does the client have a history AND documentation of hypoglycemia of either of the following:*

Recurrent Level 2 hypoglycemia events that persists despite multiple attempts to adjust medications and/or modify the diabetes treatment plan?a history of one Level 3 hypoglycemic event characterized by altered mental and/or physical state requiring third-party assistance for treatment of hypoglycemiaNone of the above
How is the client receiving insulin?*

ContinuouslyManually
How many times a day does the client manually received insulin?
How is the insulin being administered?*

InjectionInhalerOther
Other- How is the insulin being administered?
List the client's diabetic medication treatment (must include freq & dose) *
Diabetes: The client has a history of... (Check all that apply)*

nocturnal hypoglycemiahypoglycemic unawarenesssevere glycemic excursionspostprandial hyperglycemiasignificant changes to diabetes treatmentunexplained hyperglycemiaunexplained, severe or recurring hypoglycemiadiabetic ketoacidosisAM hyperglycemia in which fasting blood glucose levels often exceed 200wide variations in blood glucose levels before lunch and/or dinnerinadequate glycemic control despite appropriate adjustments in insulin therapy and compliance with frequent self monitoringrecurring episodes of severe hypoglycemiaNone of the above
Type of Cane or Crutch?

Straight CaneQuad CaneCrutchesForearm Crutches
Cane Base/Type

NarrowWideBariatric
Does the client need a Crutch Platform Attachment?
Why is the client unable to use a regular toilet?*

muscle weaknessfall riskdifficulty walkinglack of assistance at nightClient is capable of reaching/using a regular toilet
Is the client physically confined to an area of the home?*

client is confined to a single roomclient is confined to 1 level of the home (no toilet on that level)client is confined to the home (no toilets in the home)none of the above
Does the client need any other items to be ordered with the hospital bed?*

Gel Overlay (must have pressure ulcers)Alternating Pressure Pad (must have pressure ulcers)Low Air Loss Mattress (must have stage 3 or 4 pressure ulcers)Full Bed RailsHalf Bed RailsTrapeze barTransfer boardNone of the Above
Why does the client require a hospital bed?*

Traction equipmentPositioning not possible with an ordinary bed (due to CHF, chronic Pulmonary disease, problems with aspiration or another medical condition)Alleviate PainNone of these
Which traction equipment is required?

Traction Frame/Fracture FrameRussell's tractionBuck's extensionDunlop's tractionSkull tongs and turning frameHead halterBalance suspensionLateral skeletal traction
What type of traction Frame is needed?

Traction Frame: Cervical- Attached to headboardTraction Frame: Extremity- Attached to footboardTraction Frame: Pelvis- Attached to footboardFracture Frame- Attachments for complex pelvic tractionFracture Frame- Attachments for complex cervical traction
Traction equipment needed to:

Prevent and reduce muscle contracturesRegain normal length and alignment of involved boneLessen or eliminate muscle spasmsRelieve pressure on spinal nervesPrevent and reduce skeletal deformities
List the underlying condition causing the client's pain*

FractureBack injuryHip injuryArthritisCancerPressure wounds/ulcersSpinal StenosisOsteoporosisOther
Which position(s) are required?*

60-90 degree head of the bed elevation45-60 degree head of the bed elevation30-45 degree head of the bed elevationOrthopedic positioning (leg elevation)Positioning for functional weight shifts
Where is the client's pain?*

ChestBackButtocksUpper extremityLower Extremity
Which condition(s) require(s) this positioning?*

Problems with aspirationCHFChronic Pulmonary DiseaseOther
List other conditions:
How severe is the client's condition or pain?*

SevereModerateMild
How long has the patient suffered from their condition or pain?*

2 years1 year6 months3 months
How as the client's condition or pain progressed over time?*

Getting worseStableIntermittent
Why does the client's condition necessitate a hospital bed?*

SOBPresence and/or prevention of pressure ulcersMuscle weaknessLower extremity edemaPainInability to move independently
What kind of changes in body position does the client need?*

FrequentImmediateFrequent and ImmediateNeither Frequent nor immediate
Why must position changes be achieved frequently and/or immediately?*

Treat bed soresTreat skin breakdownTreat muscle contracturesAlleviate PressureAlleviate PainAlleviate orthopneaAssist with breathingAssist with swallowing difficultiesAssist caretaker in bathing, dressing, or feeding the clientAssist caretaker in completing exams or procedures
Bathing- What type of bathing product is needed?*

BenchChairStationary Transfer benchSliding Transfer bench
Bathing- What does the chair/bench need?

A backArmrestsBariatric Size option
Bathing- Select all reasonings client needs bathing bench/chair*

Decreased BalanceMuscle WeaknessMobility difficulties
Walker or Rollator?*

RollatorBariatric RollatorFront Wheeled WalkerFolding Walker (no wheels)Bariatric Wheeled Walker (over 300 lbs)Junior Wheeled Walker
Walker/Rollator ICD-10 Code:*

M62.81- Muscle WeaknessR53.1- WeaknessR06.02- Shortness of BreathR26.2- Difficulty in walkingZ91.81- History of fallingR26.89- Other abnormalities of gait and mobilityR26.81- Unsteadiness on feetOther
Which mobility-related activities of daily living (MRADLs) are impaired?*

Walking independentlyToiletingFeedingDressingMaintaining hydiene
Which of the following statement describes the patient's inability to complete there MRADLs?*

Entirely unable to completeUnable to complete in a reasonable timeframeAttempts would heighten the risk of morbidity or mortalityNone of these
Wound Vac- Please List the Location(s) of the wound(s), the onset date of the wound(s) and when/if the wound(s) were debrided.
Wound Vac- Has the patient done Wet to Dry dressings on the wound(s)?

Yes- Wet with SalineYes- Wet with VasheYes- Wet with otherNo
Wound Vac- What is the Pressure needed for the Vac?
Wound Vac- What type of Foam/Drape is needed

Peel & Place Dressing KitGranduFoam with Dermatac DrapeGranduFoam with regular DrapeSimplace Dressing with regular Drape
Wound Vac- Size of Foam needed?

SmallMediumLarge
Wound Vac- Does the patient also need White Foam?

Yes- SmallYes- LargeNo
Wheelchair/Scooter- What is needed?*

Standard Manual WheelchairBariatric Manual WheelchairStandard Transport WheelchairBariatric Transport WheelchairReclining WheelchairElectric Wheelchair/Scooter
Width of Hips in Inches*
Seat Depth*

16 Inches (Standard)18 Inches (Tall)20 Inches (Extra Tall)
Seat Height*

StandardHemi Low Seat
Standard Wheelchair Accessories*

Desk Armrest LengthFull Armrest LengthAdjustable Armrest HeightSwing Away Leg Rest Both feetSwing Away Leg Rest Right FootSwing Away Leg Rest Left FootElevating Leg RestsArticulating Leg RestsNone of the Above
Power Wheelchair Accessories*

ArmrestsElevating Leg RestsOxygen Tank HolderOtherNone of the above
What is the primary reason the patient needs a power mobility device (PMD)?*

Respiratory illnessCardiovascular illnessNeuromuscular illnessAmputation of ExtremityOther
Other Primary Reason pt needs a PMD*
Select all MRADLs in the home that are impaired*

BathingToiletingFeedingDressingGroomingOtherNone
Other MRADL that is impaired *
Which of the following describes the pts inability to complete these MRADLs in the home? (Select only 1)*

Unable to complete in a reasonable timeframeAttempts would heighten the risk of morbidity and mortalityEntirely unable to completeNone of the abover
Which of the following symptoms occur when the pt attempts ADLs?*

Shortness of BreathChest TightnessChronic CoughingOther
Other symptom that occurs when pt attempts ADLs*
What interventions help alleviate these signs/symptoms?*

OxygenNebulizerInhalerOther
Other intervention that help alleviate signs/symptoms *
Have these signs/symptoms changed over time?

Gotten WorseStayed the SameImproved
How is the patient's mobility limited without a PMD?*

Bedbound & needs PMD for safe transferHas severe difficulty walkingHas a high risk of fallingRelies on caregiver assistanceis too weak to walk safely independentlyhas diminished endurance levels & activity toleranceOther
Other mobility limit without PMD*
The patient has used the following in the past:*

CaneCrutchesWalkerRollatorManual Wheelchair
Explain why the cane/walker/wheelchair in the past proved to be insufficient
Pressure Reducing Surface*

Foam MattressGel over-lay MattressAir-filled MattressLow Air Loss MattressPowered Alternating Pressure MattressFoam CushionGel CushionAir-Filled CushionCombination Cushions
Does the patient have multiple stage 2 pressure ulcers or at least one Stage 3 or 4 Pressure Ulcer on the trunk of their body?*

YesNo
PT/INR Machine- Has the patient been on Coumadin for at least 90 days?*

YesNo
PT/INR Machine- Who is going to perform the POCT in the home?*

Patient is able to be trained & perform POCT for PT/INRPatient has a caregiver that is able to be trained & perform POCT for PT/INR
PT/INR Machine- Has the provider agreed to monitor the patient with POCT in the home for PT/INR? - Please note that most Coumadin Clinics will NOT continue to monitor patients if they have their own INR machine. If the pt is being monitored by a Coumadin Clinic, the PCP or Cardiologist may have to agree to take back monitoring*

YesNo
PT/INR Machine- What provider is going to be monitoring the INR Results? *
Due to the information given, the client does not meet the requirements for insurance to cover this item.
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